AIM: To compare ultrasound-guided vertebroplasty (percutaneous vertebroplasty, PVP) with X-ray guided vertebroplasty (PVP) to confirm the success rate of puncture point, X-ray radiation dose, operation time and postoperative outcome to explore the clinical application value of ultrasound-guided vertebroplasty. METHODS: Patients with thoracolumbar vertebral compression fractures treated by PVP in our hospital from November 2018 to October 2021 were divided into ultrasound-guided group and X-ray guided group. The success rate of puncture, the X-ray radiation dose, operation time and postoperative outcome were compared between the two groups. RESULTS: A total of 97 patients were included in this study, with an average follow-up time of (14.412±10.261) months. The success rate of one-time puncture was 60.4% in the ultrasound-guided group and 30.6% in the X-ray guided group (P<0.05). The X-ray radiation dose, fluoroscopy times and operation time in the ultrasound-guided group were significantly lower than those in the X-ray-guided group (P<0.05). The difference was statistically significant (P<0.05). The VAS of low back pain was significantly relieved in the two groups, but there was no significant difference between the two groups. There were no postoperative complications such as infection, puncture site hematoma and fracture nonunion between the two groups. CONCLUSION: Ultrasound guidance is a safe and effective method to determine the needle entry point of PVP. Skillful operation can improve the success rate of one-time puncture. Compared with traditional X-ray guidance, it can shorten the operation time, reduce the number of X-ray fluoroscopy and radiation during PVP operation.